spenac Posted May 24, 2009 Posted May 24, 2009 I messed up my vote, sorry! I misread the question and voted "yes" when I should have voted "no." I think the answers should be posted in the original topics, to avoid clutter. If you want to obscure the answers you can highlight them with black so that users need to specifically "reveal" the text before they can read it... Excellent idea. How do you do that?
FL_Medic Posted May 24, 2009 Author Posted May 24, 2009 I'm not a guru, Adam. Just a guy with strong opinions. Some of them might even be right! Tom B. Well I would reccomend your blog to anyone reading this. There is a specific tutorial on there that might help them with this very strip. .
Niftymedi911 Posted May 24, 2009 Posted May 24, 2009 (edited) Alright Adam I waited enough..... I'm calling it V-tach. The right ward axis, wide complex (its completely ventricular in nature) lack of P waves, and rate in itself all show the rhythm. Tom, wouldn't that suck major if no 12 lead was done on this patient? Lead II totally sucks in this one. Every cardiac monitor defaults to Lead II, this just goes to show you, that you must not always think "inside the box". I'm a strong believer of not using lead II as a simple strip on the monitor, for this reason! Lead III and V1 are much much better. Edited May 24, 2009 by Niftymedi911
Tom B. Posted May 24, 2009 Posted May 24, 2009 For rhythm analysis, I like any lead that shows good P waves, QRS complex, and T waves. At least with a 12 lead, you've got your choice! Tom B. Alright Adam I waited enough..... I'm calling it V-tach. The right ward axis, wide complex (its completely ventricular in nature) lack of P waves, and rate in itself all show the rhythm. Tom, wouldn't that suck major if no 12 lead was done on this patient? Lead II totally sucks in this one. Every cardiac monitor defaults to Lead II, this just goes to show you, that you must not always think "inside the box". I'm a strong believer of not using lead II as a simple strip on the monitor, for this reason! Lead III and V1 are much much better.
FL_Medic Posted May 24, 2009 Author Posted May 24, 2009 Alright Adam I waited enough..... I'm calling it V-tach. The right ward axis, wide complex (its completely ventricular in nature) lack of P waves, and rate in itself all show the rhythm. Tom, wouldn't that suck major if no 12 lead was done on this patient? Lead II totally sucks in this one. Every cardiac monitor defaults to Lead II, this just goes to show you, that you must not always think "inside the box". I'm a strong believer of not using lead II as a simple strip on the monitor, for this reason! Lead III and V1 are much much better. I am still going to let this one go longer before I reveal the answer. Lead II is chosen as the monitoring lead because the normal heart should have an axis between 0 and 90 degrees. Lead II falls where? At 60 degrees. In the "normal" heart, using only bipolar leads. lead II should be the best representation of ventricular depolarization. This is why aVR is the most ignored lead, it's negative pole is at 30 degrees meaning that unless you are in "no mans land", this lead will be negative, and show the worst picture. Unfortunately we are presented with many patients that have axis devaition. If you have better success getting a bigger positive QRS in lead III, it is because your patients are probably presenting with physiological rightward axis deviation. v1 typically presents with an rS pattern in the normal heart. It does however, usually give the pest picture of your p waves. Why? Just look at where you place v1, if you had x-ray vision, you would probably see the right atrium directly underneeth the lead. Where is the p-wave producing SA node? In the right atrium. A 12-lead is a good way to figure out which lead to monitor, or the typical scroll through. I agree that lead II should not be the single go-to lead. Neaither should lead III, or v1. Not V-tach, SVT with aberrancy and BBB why?
p3medic Posted May 24, 2009 Posted May 24, 2009 Not V-tach, SVT with aberrancy and BBB Disagree, but curious as to your explanation.
chbare Posted May 24, 2009 Posted May 24, 2009 This is one case where you cannot rely solely on axis deviation to make the call. It looks like RAD using the three lead method; however, the criteria for right shoulder deviation does not exist. With that, I am still thinking we are dealing with ventricular tachycardia: 1) The rhythm is regular, and I do not think we have an underlying atrial fibrillation or flutter. 2) I cannot see any re-entry morphology such as Delta waves. 3) Looking at lead III, I think we have a couple of random P waves, this points to AV dissociation, a finding that pretty much rules out SVT. I would be willing to consider a good argument for SVT with aberrancy; however, too many things are pointing to ventricular tachycardia at this point. Take care, chbare.
HellsBells Posted May 25, 2009 Posted May 25, 2009 My first reaction was to call this a junctional tach with RBBB, but as chbare pointed out, there are a few scattered p waves in lead III, and in the 3rd, 11th, and 14th complexes of V1 at the bottom, so now I'm not so sure... leaning more towards V-Tach. Oh, and to the poster that diagnosed a BBB due to "rabbit ears," my understanding is that its not a very reliable indicator.
chbare Posted May 25, 2009 Posted May 25, 2009 No it is not a definitive indicator for confirming a RBBB. However, it is not an uncommon finding in the presence of a BBB. However, the notching I see with this rhythm is significantly different from any rabbit ears pattern I have even seen. In fact, it does not even fit into any recognizable QRS pattern I know such as an RSR prime pattern. It looks somewhat like the dicrotic notch of an arterial waveform. (In V1 specifically.) With the notch on the descending slope of the waveform. This IMHO is more evidence to support the theory of ventricular tachycardia. Take care, chbare.
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